Invisible illness: The consequences of limited health insurance in Africa

Abstract Background Limited health insurance coverage in Africa poses a significant challenge, impeding access to quality healthcare for millions of individuals. Methods This paper synthesizes information from existing literature and research on the topic of limited health insurance coverage in Africa. The identified consequences and root causes are presented in a structured format. Results The consequences of limited health insurance coverage in Africa include increased financial burden on households, decreased access to health services, and inadequate coverage for essential health services. These consequences contribute to reduced utilization of healthcare services and negative health outcomes, including the deterioration of existing health conditions and the development of new health problems. The financial burden is particularly significant due to high poverty rates in Africa, forcing households to pay for healthcare services out of pocket and leading to considerable financial strain and even financial ruin. Additionally, limited health insurance coverage restricts access to necessary health services, resulting in delayed treatment, missed diagnoses, and poor health outcomes. Conclusion The root causes of limited health insurance coverage in Africa are multifaceted and include factors such as poverty, lack of government support, and limited private‐sector involvement. These systemic issues contribute to the persistence of inadequate health insurance coverage and hinder efforts to improve access to quality healthcare for African populations.

obstacles in accessing quality healthcare services, leading to untreated conditions, delayed diagnoses, and poorer health outcomes. 3 Additionally, healthcare providers cannot provide quality care to those who need it without a sustainable financing mechanism.
The limited access to health insurance also impacts the healthcare system, leading to overburdened health facilities, shortages of medical supplies and personnel, and a decline in the quality of care provided. 4 In sub-Saharan Africa (SSA), a significant number of countries, specifically 27 out of 48, are affected by direct OOPs for healthcare services that exceed 30%, which annually impoverish over 100 million people, primarily in low-and middle-income countries. 5 To address the issue of catastrophic health expenditures, it is crucial to develop solutions that improve access to quality healthcare services and financial protection for all. This review aims to examine the consequences of limited health insurance coverage in Africa, identify the factors contributing to limited health insurance coverage, and identify potential strategies for improving health insurance coverage and access to healthcare services. By understanding the consequences of limited health insurance coverage, interventions can be developed and implemented to improve access to quality healthcare services and financial protection.

| FACTORS CONTRIBUTING TO LIMITED HEALTH INSURANCE IN AFRICA
In Africa, poverty and limited access to health insurance are major barriers to universal health coverage. According to the World Bank, over 50% of the population in this region lives in extreme poverty, making it difficult to afford even basic healthcare services. 6 Moreover, studies have shown that low-income households are less likely to have health insurance coverage than higher-income households, with cost being a significant barrier. 7,8 This situation seriously affects the health and well-being of African individuals and communities. Without access to adequate healthcare services, preventable illnesses, and chronic conditions can go untreated, leading to unnecessary suffering and premature death. 4 Moreover, out-of-pocket healthcare payments can drive people further into poverty, perpetuating a vicious cycle of poor health and economic insecurity 9 (see Table 1). Addressing these challenges requires a comprehensive approach that tackles poverty and its underlying determinants.
Limited government infrastructure is another significant factor contributing to the limited health insurance coverage in Africa.
Without proper infrastructure, governments often cannot establish or effectively run health insurance programs, leading to limited coverage. 10  For instance, the M-TIBA platform in Kenya enables users to save and access funds for healthcare services, facilitates the payment of health insurance premiums, and provides a digital record of healthcare transactions. 25 While progress has been made in expanding access to health insurance through various strategies, future efforts should focus on several key areas. There is a need to strengthen healthcare infrastructure and systems, particularly in rural and underserved areas. This includes improving the availability and quality of healthcare facilities, equipment, and personnel, as well as strengthening health information systems to support the implementation and monitoring of health insurance programs. In addition, efforts should be made to improve the affordability and accessibility of health insurance products for low-income households. This can be achieved through the development of innovative and flexible health insurance products, as well as the provision of subsidies and financial assistance to low-income households to enable them to access health insurance.
Furthermore, there is a need to increase public awareness and education about the benefits of health insurance and the available options (see Table 2). This can be achieved through targeted public writing-review and editing.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no data sets were generated or analyzed during the current study.

TRANSPARENCY STATEMENT
The lead author Aderinto Nicholas affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; T A B L E 2 Key factors and policy recommendations for limited health insurance coverage Africa.

Factor Example Policy recommendation
High poverty rates In many African countries, a significant portion of the population lives in poverty and cannot afford health insurance premiums.
Develop targeted subsidies or vouchers to support lowincome individuals and families in accessing health insurance. Increase funding for social health insurance programs to expand coverage to vulnerable populations.

Lack of healthcare infrastructure
Many African countries have limited healthcare infrastructure, which makes it difficult to implement and support health insurance programs.
Increase investment in healthcare infrastructure to support the development and expansion of health insurance programs. This could include funding for the construction of healthcare facilities and the training of healthcare workers. Develop public-private partnerships to leverage private sector resources and expertise in building healthcare infrastructure.

Limited regulatory frameworks
Many African countries lack robust regulatory frameworks for health insurance, which can hinder the development and implementation of effective programs.
Provide technical assistance to national governments in developing and implementing regulatory frameworks for health insurance. This could involve supporting the development of legislation, regulations, and guidelines for health insurance, as well as providing training and capacity building for regulatory agencies.

Fragmented healthcare systems
In many African countries, healthcare systems are fragmented and decentralized, which can make it difficult to implement and manage health insurance programs.
Develop coordinated approaches to healthcare delivery that involve collaboration between different healthcare providers and stakeholders. This could involve the development of integrated health systems or the establishment of referral networks to facilitate access to specialized care.

Limited public awareness
Many individuals in Africa are not aware of the benefits of health insurance or how to access it.
Develop public education campaigns to raise awareness about the benefits of health insurance and how to enroll in programs. Use community-based approaches to engage individuals and families in health insurance enrollment and utilization.
Political instability Political instability and conflict can undermine the development and implementation of health insurance programs.
Work with national and international partners to address underlying political and security challenges that impact healthcare delivery. Provide technical and financial support to strengthen healthcare systems in conflictaffected areas.
NICHOLAS and DEJI | 5 of 6 and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.